Credit Card Authorization Form

    Ann E. Drouilhet, LICSW, LMFT
    40 SPEEN ST. Ste. 106
    FRAMINGHAM, MA 01701
    508-877-3660 x2
    adrouilhet@gmail.com

    CREDIT CARD AUTHORIZATION FORM



    Company Information
    LEGAL NAME OF BUSINESS OR INDIVIDUAL AUTHORIZING CHARGE (If corporation list full corporation name).
    Physical Business Street Address (No P.O.Boxes):
    City
    State
    Zip
    Fax No:

    Credit Card Information


    Credit Card Number:
    Exp Date:
    CVV (3 digits at the beck of credit card/ 4 digits on the front of Amex Card):
    Name, exactly as it appears on card:

    Mailing Address on File with Credit Card Company (lf you are unsure please call your Credit Card Company). lf this address ls not correct it will delay the shipping of your merchandise.

    Street:
    City/State
    Zip

    The undersigned hereby declares that the credit information listed above is true, accurate and appears in the name as stated and authorization is hereby given to the above named individuals to use these cards for purchases from merchant name . Further, I authorize my credit card company to accept and to charge to my account for purchases initiated by the above named individuals. This authorization allows Merchant name to continue to use this information and such information shall remain in full force and affect unless I revoke such authorization in writing.